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The gap in cancer care was highlighted in a 1999 report from the Institute of Medicine’s National Cancer Policy Board, which prompted several major initiatives aimed at measuring and improving the quality of cancer care.
In 2006, the first national study to assess the quality of cancer care showed that patients with early-stage breast cancer received 86 percent of generally recommended care, while patients with early-stage colorectal cancers received 78 percent of generally recommended care. Commissioned by ASCO, this research for the first time quantified the cancer care gap based on nearly 1,800 patient surveys and medical records in five major metropolitan areas. The study did indicate the quality of cancer care generally was better than that for some other common diseases, such as hypertension and diabetes, but more analysis will be needed to learn why care differed, in some cases dramatically, says Johnson, Cornelius Abernathy Craig Professor of Medical and Surgical Oncology.
“This is a treasure trove of data,” Johnson says.
In the meantime, experts say, patients should arm themselves with information as they navigate their way to the cancer care decisions that are best for them.
The importance of a second opinion
If a cancer diagnosis happens to come from an experienced
cancer specialist with top-notch credentials, a patient may not feel the need to get a second opinion before beginning treatment. However, with a potentially life-threatening disease like cancer,
most doctors expect – in fact, some even encourage – patients to
seek advice from another physician.
“They have to depend on their doctor,” says Johnson. “I think with cancer, you have to assume a doctor who is board certified is, in fact, a capable individual. However, I think it’s quite appropriate to get a second opinion.” Even so, insurance coverage for second opinions varies by policy and type of treatment, so in some circumstances patients may face paying for this reassuring step.
The first goal in the second-opinion process should be to confirm the diagnosis (see story on p. 33). At Vanderbilt-Ingram, all reports and pathology slides are reviewed when a patient comes for a consultation, and additional tests are done if necessary. This intense
evaluation is important because all cancers are not alike. A doctor who routinely treats just one or a few types of cancer may use specialized knowledge and diagnostic tests to evaluate the type and extent of a cancer – called staging – which is imperative to getting the most appropriate treatment at the start of care.
While the Internet and other sources have made it possible for patients to learn a lot about their disease, ultimately they will need to rely on a trusted medical professional to help them evaluate that information, says Johnson.
“What most patients want is guidance,”
he says.
Seek out experienced physicians and facilities
All board-certified oncologists should have the same basic credentials. However,
specialized centers, particularly those associated with universities, have experts who focus on specific cancers and benefit from access to world-class research and technology.
“It’s volume and specialization; it’s a multidisciplinary team approach that distinguishes academic-based centers,” Johnson says. “The culture at a teaching institution like Vanderbilt is such that every decision is questioned and reviewed by one’s peers very, very thoroughly, so what emerges is a very appropriate plan for each patient.”
While these are not the only factors that affect outcome, survival statistics for patients treated at major cancer centers for certain malignancies exceed those of people treated by less specialized doctors and facilities, Johnson points out. Doctors who treat just one or a few specific cancers statistically are better at it, and those who specialize in rare or aggressive cancers may have unique expertise.
“Patients generally can understand how experience relates to outcomes,” says Joseph A. Smith, M.D. “In particular, urologic cancer outcomes are directly related to the training and expertise of the surgeon.”
Smith chairs Vanderbilt’s Department of Urologic Surgery, which is ranked among the nation’s best in this specialty by U.S. News and World Report and includes physicians who are nationally recognized experts in a variety of urologic cancers. The department also has been a leader in robotic and minimally invasive surgical
procedures.
Vanderbilt’s urologic oncologists see patients referred by urologists in the community, as well as family physicians. That number includes many patients with prostate cancer, for whom treatment recommendations can be diverse and confusing.
While it isn’t common for a patient to get a different diagnosis at Vanderbilt, it’s not unusual for treatment recommendations
to differ, especially when combined regimens are considered,
Smith says.
“Selecting the right treatment for the right cancer is key,” he says.
Joe B. Putnam Jr., M.D., deals with many cancers that don’t come with a lot of good treatment options. Well-meaning doctors sometimes rush patients into treatment when time might be better spent carefully diagnosing the stage of the cancer, determining the best treatment sequence and considering other factors, explains Putnam, Vanderbilt’s chairman of Thoracic Surgery.
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